Your care team writes notes after every visit and typically once a day in the hospital. Notes contain what you, your doctor, and other members of your care team talk about during your visits, plans for your care, and what is recommended to improve your health and wellness. Notes include things like a summary of your visit, your health goals, your questions and concerns, your medicines, home care, and your care plans.
Clinical notes do not always look the same. Care team members may write them in different ways based on their clinical roles and how they are used to coordinate your care with your care team. If you do not understand something in your record, please let your doctor know.